April 14, 1999 12:44PM (UTC)

I did my first pelvic exam on Valentine's Day. And my first prostate exam.
And my first testicular exam.

The genital exam was taught in an evening session where my classmates and I
practiced on professional patients trained to teach us the necessary skills
-- two hours for the female exam and another two for the male. As February
14 approached, I was filled with anxiety. This exam was by far my least
favorite part of my own regular physicals, and I was unsure how I would
respond now that I had assumed the physician's role.

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I had spent the last one and a half years of our Patient-Doctor clinical
skills course learning how to question patients about their sexual
practices and concerns. I worked to become more comfortable with the
issues we probed and the information we gleaned. I struggled to make my
patients -- and myself -- feel comfortable discussing topics fraught with
taboo. But now I crossed the physical boundary. It was no longer
discussion in the abstract; I observed, examined, and palpated. My
classmates also struggled with these issues. For the first time we had to
extricate ourselves from our sexual associations, cultural values and
personal beliefs about genitals and transform them into a purely clinical
experience.

After watching a very clinical -- and very graphic -- video of the pelvic
exam and practicing the exams on plastic male and female dummies in
preparation for our teaching session, my classmate Scott said, "Will sex
ever be the same for us again?" As we struggled to achieve clinical
objectivity, sometimes the boundary felt blurred.

Our first exams were staggered to accommodate small student groups -- they
had been running nightly sessions for months by the time my turn came.
Those of us scheduled for later slots questioned classmates who had already
gone through their training session. It really wasn't too bad, Masha
reassured me. "You get so caught up in looking for the structures, you
forget what you're actually looking at," she said. Her "patient" had
bruises on her abdomen from students attempting a bimanual palpation of the
ovaries. In focusing on the physical, some of my classmates lost sight of
the person.

Andrea was thrilled with her first pelvic exam. She came into tutorial the
following morning glowing from her experience. "I'm going to be a vagina
doctor. I just know it. I'm going to be a vagina doctor!"

Despite my trepidation about the upcoming exam, Scott said he wasn't
particularly concerned about the session. These patients were trained.
They were knowledgeable about the exam, comfortable with being examined,
and fully aware of our complete inexperience."The first exam doesn't bother
me," he said. "It's the second that I'm worried about." He feared his
first exam on a real patient.

When confronted with real patients, my classmates and I would be forced to
grapple with our patients' perceptions of the exam and their issues
concerning genitals, not to mention our own. Insecurities about our
clinical inexperience would compound the struggle.

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Patients are legitimately concerned that we physicians will fail in our
attempt to extricate the sexual aspect of genitals from the clinical exam.
In particular, women have become increasingly aware of the sexual
harassment risks involved in the pelvic and breast exams. They routinely
request female examiners, and in our lecture on these exams the physician
recommended that we always perform them with a chaperone in the room. Even
she, a woman, did not do them alone, unless she had already established a
long-term relationship with the patient.

Yet the increasing desire for patients to protect their privacy frustrated
some of my male classmates in their attempt to learn the female exam and
gain clinical experience. The course description of the
obstetrics-gynecology clinical rotation at one of the Harvard sites warned:
"Many HCHP [Harvard Community Health Plan] patients strongly prefer a
female physician and decline examinations by male students."

A fourth-year student complained, "If you're a guy, you just can't learn
it. None of the patients will allow us to watch. If you ask first, they
always say no. I didn't do a single gynecological exam and I watched only
one birth during my entire ob-gyn rotation. So you have to be aggressive if
you want to learn it," he said. Another male student disagreed. But he
emphasized the importance of getting to know the patient, if possible,
before starting the procedures.

If the boundaries between emotional and clinical, cultural and medical were
difficult for us to draw at times, our patients also struggled to make the
distinction. When entering the intensely private relationship of a
physical exam, they sometimes blurred the distinction between a
professional and personal relationship. Our patients flirted.

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One of my classmates practiced a mental status exam on a
thirty-five-year-old male patient. Clearly psychologically competent, the
patient was bored with the simple exercises to determine memory, reasoning,
and judgment. When my classmate pointed to her shoe and asked him to
identify it, he said, "Nice foot, nice ankle, nice knees, nice thighs.
Want me to go any higher?" She was taken aback.

"At the time I just sort of laughed it off. I didn't know what else to do.
I sort of thought it was my fault, like maybe I hadn't set a formal enough
tone. Maybe I was just too casual and jokey," she said.

An older male patient kept touching Renu's hair and brushing it back as she
leaned over him with her ophthalmoscope to visualize the retina on the back
surface of his eye. To do the exam correctly, the examiner had to be
within inches of the patient. "You can come closer. I really don't mind,"
he told her.

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"The worst part was that he clearly knew that I knew he was flirting with
me. He was from another culture, and maybe that was more acceptable where
he came from. But it was very uncomfortable. I didn't know what to do,"
she said.

My male patients often thought I, as a young, small woman, was cute. Some
of the older men identified me with their granddaughters, and one patient
even surprised me with a familial peck on the cheek as I left. But some of
them used a distinctly more sexual tone. I preferred a slightly less
formal tone in my patient relationships, but these attitudes made me
uncomfortable. I never found a way to discourage this atmosphere from
creeping into my patient experiences. I even accepted it because these men
were often willing patients and didn't complain about the two-hour
histories and physicals I subjected them to.

The struggle to maintain a distinction between the clinical and the
personal invaded the classroom as well. As we learned the different
components of the physical exam, we practiced on one another. While we did
not perform the genital exam on one another, some of the other procedures
were nearly as sensitive. As we entered these pseudo patient-doctor
relationships with one another, the boundaries between companion,
colleague, and patient became blurred. We didn't fit into any category.

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Carlos's patient-doctor group learned to palpate the inguinal lymph nodes,
which were in the groin. I asked him how the session had been.
"Revealing," he said.

Carlos acted as the patient for the group. As the patient he sat in his
boxer shorts in front of a mixed-sex group of our classmates as the
instructor demonstrated the exam and the students practiced. Both male and
female classmates in his group had to feel under his shorts to palpate the
nodes. Roy wore double underwear -- Jockeys and boxers -- to minimize the
invasiveness and embarrassment inherent in the situation.

After all the buildup for the event, my first internal pelvic exam was not
such a big deal. I think one reason for my fear was that as a woman and
unlike a man, I had never really seen my own genitalia. This was foreign
territory. And since I experienced my own exams as a humiliating
procedure, I feared inflicting the same humiliation on another person.

Lisa, our professional patient, was completely at ease. These "patients"
were trained to teach us the genital exams, using themselves as models.
Because I arrived a little early, I met Lisa outside the examining room
just as she was coming in. Lisa was probably only five or six years older
than I was. An obese woman, she had permed shoulder-length mousy hair and
pale blue eyes. As we waited for the administrator organizing the evening
program, I felt compelled to make conversation. "Thank you for doing this
for us. We really appreciate your coming to teach us," I told her.

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"Oh, yeah, well, I like coming. And it's a great way to make money," she
said. Lisa had burned out in her teaching job a few years ago. Looking to
change professions, she had come across an advertisement for volunteers to
act as patients for medical students. "It just seemed like a great
opportunity at the time. And so many women die of breast cancer that I
think it's important that you guys know how to do a good exam. I'll probably do this for a few more years before I move on to something else."

When our turn came to examine Lisa, Scott and I entered the room to find
her in a johnny sitting on the examining table. Lisa had been trained both
to show us how to do a proper exam and to act as the patient. She knew
exactly how each part of the exam was supposed to feel and helped modify
our technique to improve our skills. First, she carefully described the
necessary motions women must make to obtain an adequate visual exam of the
breasts. Then she lowered the top of her johnny to reveal her pendulous
breasts. She flexed her arms as we watched, and then lifted them and
clasped her hands behind her head. We watched her breasts change shape as
the chest wall muscles behind them tightened and relaxed. Then she lay
back so we could practice the breast exam. Scott went first. "No, you
have to press harder. I could still have a lump there that you wouldn't
feel."

As his fingers worked meticulously across her breast, he found dense
fibrous scar tissue at the base of her breast. "That's from my breast
reduction surgery. It's completely normal. But you should feel it so that
you know what it's like." As he lifted her breast to reach the tissue
better, I noticed the three-inch ruddy crosshatch scar.

Then it was my turn. I carefully moved my fingers in small circles across
the entire surface of her breast. "That's good. The pressure is just
right." I found the fibrous shelf of scar tissue at the base of her breast,
and I ran my fingers across the scar.

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Now came the part I dreaded. I arranged the light for Scott as Lisa pulled
her johnny up to cover her shoulders and then spread a paper sheet across
her lap. She pulled out a blue plastic hand mirror while I ran warm water
over the speculum, the gray metal instrument used to open the vagina and
visualize the cervix, the opening of the uterus. She showed Scott how to
feel her labia and the soft mound of her mons over the pubic bone for
masses. She told him how to spread her labia majora to reveal the wrinkled
pink labia minora inside.

As Scott inserted the speculum into her vagina, Lisa held the blue plastic
mirror so she could see what he was looking at. "Okay, now that the
speculum is in, you have to rotate it ninety degrees and push it toward the
back of the vagina. And most important, be careful to keep pressure toward
the floor on the speculum. You don't want the speculum to ride up and hit
my clitoris. That's excruciatingly painful for women."

Scott advanced the speculum. Small beads of sweat accumulated on his brow.

"Oh ... you need way more pressure. You're getting close to my clitoris,"
Lisa warned.

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When it was my turn, I tried to follow the directions she had given Scott.
I inserted the metal speculum and then rotated it ninety degrees.

"Watch my clitoris. A little more pressure."

I pushed the speculum to the end of her vagina and then opened the lips of
the speculum. I saw a pink tissue wall with streaks of creamy white mucus.
This didn't look at all like the cervix.

Lisa surveyed the situation in her hand mirror. "Why don't you try closing
the lips, aiming more toward the floor, and pushing the tip in a little
farther?"

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I pushed the speculum a little farther and opened the blades again. Still
the same pink wall. I could feel my face warm under the hot light of the
lamp. I tried one more time, and this time was grateful to see the raised
pink doughnut of the cervix with the central red spot identifying the
passageway into the body of the uterus.

The bimanual exam was much more difficult for me. I pushed my gloved and
lubricated right fingers into her vagina, reaching for the cervix I had
just seen. I pressed my left hand into her soft abdomen, trying to press
on the uterus and bring the cervix into reach of my finger. I reached with
both my hands, but the cervix remained elusive.

"Push your fingers in farther," Lisa said.

I leaned toward her, in part using my weight to force my fingers a few
millimeters deeper into her vagina. I couldn't find the uterus in the
ample softness of her belly.

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"My uterus won't be all the way up there. You've got to press lower.
Here." She reached down and rearranged my hand. Finally I was rewarded by
what I thought was the light touch of the cervix passing across my finger.
Relieved, I finally extricated my fingers from her vagina still a little
unsure of what I felt and fairly certain I would not be able to replicate
that exam on another patient.

Although I had worried about how I would feel in the room with Lisa, she
was so matter-of-fact that she put me at ease. Once reassured that she was
comfortable with the exam, I could relax and focus on finding and examining
the necessary structures. It was hardest to watch Scott attempt the pelvic
exam, knowing that my turn was fast approaching. Once involved in the
exam, I became so absorbed in my efforts that I forgot my personal
inhibitions. After leaving the room, I thought that while I might be
technically incompetent when examining my first patient, I had at least
begun to tackle my fear of the exam. I felt confident that I would be able
to treat the pelvic as a routine part of the physical exam.

Ironically, I was less afraid of the male genital exam, although I wasn't
sure why. Perhaps I had spent so much anxious energy preparing for the
female exam that I couldn't get as worked up over the male exam. Or
perhaps my experience with Lisa was such a relief that I was no longer
worried about learning the male exam.

I recognized our patient's name. Mr. Miller had taught Kate, my roommate,
and her partner the genital exam a few weeks previously. He was a tall,
thin man in his mid-sixties. He and his wife had trained to be patients a
few years ago when his wife was diagnosed with breast cancer after her
primary clinician had missed a lump. "We really want you to learn this well so that you won't miss any lumps." His wife was in poor health and had recently stopped acting as a patient.

When Scott and I entered the examining room, Mr. Miller wore a blue
pinstripe shirt with blue chinos. We were the second session for the
evening; he had already taught two of our classmates. First he quizzed us
on the statistics for testicular cancer and made sure we knew what to look
for on the physical exam. Then we talked about language.

"Never ask a man to spread his legs. It's too demeaning," he said.
"Instead you should ask him to move his legs apart. If he gets an
erection, you can just stop the exam and continue later." We discussed how
to teach a man to do his own exam.

After the short talk we left the room so Mr. Miller could change. When we
returned, he was wearing a white T-shirt, blue chambray boxers, and black
dress socks. We practiced the exam on him, all the while demonstrating how
we would teach him to do his own self-exam. This exam was much less
involved than the female exam, and it took only half an hour to learn.

I palpated the shaft of his penis and practiced rolling back the foreskin.
"Never, never forget to replace the foreskin. It's a very sensitive area,
and it can be painful if you don't replace it," Mr. Miller reminded me. I
released the foreskin and practiced rolling it back between my thumb and
first finger again. Afterward I tried my first prostate exam. I had been
told the prostate would feel similar in consistency to the tip of my nose.
After following his directions, I inserted my finger into his rectum and
felt the smooth firmness of the prostate beneath the pad of my finger. I
felt across the smooth base of the prostate, but try as I might, my finger
would not reach to the top of his prostate. "You've got to really lean
into me." I pushed a little harder, still impossibly far from the apex of
his prostate. Finally, I removed my finger. I was relieved to have all my
first genital exams over.

Ellen Lerner Rothman

Ellen Lerner Rothman, M.D., lives in
Brookline, Mass. She is doing her
residency in the Boston Combined
Pediatrics Program at the Boston
Children's Hospital and the Boston City
Hospital. "White Coat" is her first book.